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42
N. G. Johnson and N. Kadoglou
As discussed in the pathophysiology and pathogenesis, serum biomarkers in patients with IGM are proving to be useful in the prediction of severity and recur­rence and should be considered in the diagnostic workup as indicated, in particular IL-6 and CRP as biomarkers for disease severity and NLR as a predictor of recur­rence. IL-33 has been proposed as a biomarker to distinguish between breast cancer and IGM alongside radiological and histological diagnostic ndings.
6 Summary
The disease process of idiopathic granulomatous mastitis is believed to be a result of initial ductal epithelial damage. The gold standard of treatment and the duration of intervention are not yet standardized with steroids, antibiotics, methotrexate, and surgery as being the most commonly used interventions. Corynebacterium, particu­larly Corynebacterium kroppenstedtii, is the bacterial agent mostly identied as a causative agent in the majority of cases reported. It has been seen as resistant to beta-lactam antibiotics but responsive to antibiotics such as doxycycline, rifampi­cin, and clarithromycin.
Serum CRP and IL-6 levels and NLR are proposed biomarkers for the measure­ment of disease severity and time to resolution in patients with IGM.TREM-1 and IL33 are triggers that have been implicated in the pathway of the disease process and present themselves as potential targets in the management of IGM.The major­ity of literature presented is retrospective as the disease is rare, making the elucida­tion of management modalities challenging. Indeed, further research is required and recent publications prove promising in the guidance of management to date.
References
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N. G. Johnson and N. Kadoglou
Imaging Studies inIdiopathic
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Granulomatous Mastitis
NevinSekmenli
1 Mammography
Idiopathic granulomatous mastitis (IGM), a chronic, benign, and inammatory dis­ease of the breast, is frequently confused with malignant lesions due to its clinical and radiological ndings. The rst radiological step in the breast imaging algorithm is mammography. The sensitivity of mammography is lower among the young pop­ulation due to the dense breast pattern [1–3].
Mammographic ndings are reported as negative in 50% of cases in the litera­ture. However, in some cases, mammographic ndings are suspicious enough to easily suggest malignancy [3]. The mammographic images may vary from one case to another. Regarding mammography, an asymmetric density with no parenchymal distortion or microcalcications and/or a mass with benign or suspicious properties and focal asymmetric density may be seen. The most common mammographic appearance in IGM is asymmetric density. In previous studies, dense or heteroge­neous dense breast patterns were observed in more than half of the cases [4]. In a study by Fazzio et al. [5], a moderate-sized focal asymmetry demonstrating the region of palpable mass was observed as the most widespread nding on the mam­mography [5].
Focal asymmetry (Fig.1), asymmetric broglandular increase in density (Fig.2), structural distortion (Fig.3), nipple retraction (Fig.4), retroareolar asymmetric den- sity (Fig. 5), trabecular thickening (Fig. 6), irregular or ellipsoid-shape density (Fig. 7), and multifocal involvement can be detected in the non-dense breasts. Additionally, there may be a thickening of the skin in the supercially involved areas.
N. Sekmenli (*) Department of Radiology, Saglik Bilimleri University, Hamidiye Faculty of Medicine, Ministry of Health Konya City Hospital, Konya, Türkiye
H. Koksal, N. Kadoglou (eds.), Idiopathic Granulomatous Mastitis,
https://doi.org/10.1007/978-3-031-30391-3_7
45© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
46
Fig. 1 Mediolateral oblique mammograms of the right and left breasts of a 41-year-old woman with IGM.A focal asymmetric density is seen in the upper portion of the right breast (arrow)
Fig. 2 A 36-year-old woman with IGM.Bilateral mediolateral oblique mammogram demonstrates regional asymmetry with indistinct margins in the middle upper portion of the left breast. The left breast size has increased globally
N. Sekmenli
Imaging Studies inIdiopathic Granulomatous Mastitis
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47
Fig. 3 Bilateral mediolateral oblique and craniocaudal mammograms of a 38-year-old woman with IGM.A focal asymmetric density with indistinct margins is seen in the upper outer quadrant of the right breast (arrows)
Fig. 4 Bilateral mediolateral oblique mammography of a patient with pathologically proven diagnosis of IGM.Skin thickening and nipple retraction of the left breast is seen (arrow). Regional asymmetry in the retroareolar and lower region of the left breast is noticed. A well­circumscribed solitary mass in the upper right breast has simple cystic features sonographically
48
Fig. 5 Bilateral mediolateral oblique mammogram of a 28-year-old woman with IGM on the left breast. There is a regional asymmetry and slightly parenchymal distortion in the retroareolar region of the left breast (arrows)
Fig. 6 IGM on the left breast in a woman. She has a palpable mass in the upper outer quadrant of the left breast. Bilateral mediolateral oblique mammogram demonstrates a large mass-like density with trabecular thickening in the upper quadrant of the left breast (arrows)
N. Sekmenli
The cases of inammatory breast cancer (IBC) present with similar manifesta­tions. However, IBC characteristically involves over one-third of the breast skin, whereas IGM seldom involves the skin extensively [6].
In many patients, the affected breast is slightly larger than the opposite breast, especially in a mediolateral oblique (MLO) view (Fig.2) [5].
IGM lesions can be observed in each quadrant of the breasts without any associa­tion with a specic quadrant.
In general, there is no relationship between IGM and calcications [5, 7]. Fazzio etal. [5] reported that calcications are a very rare mammographic nding of granu­lomatous mastitis via a single case appearing as segmental coarse heterogeneous calcications [5].
Imaging Studies inIdiopathic Granulomatous Mastitis
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Fig. 7 Bilateral mediolateral oblique mammogram of a 28-year-old woman with IGM on the left breast. A nodular density with indistinct margins is seen in the retroareolar region of the left breast (arrow). Fibroglandular texture distribution is symmetrical in both breasts
2 Ultrasonography
49
Since IGM is encountered more commonly among premenopausal women present­ing with mastitis and mass-like ndings, the rst-line diagnostic tool is examination through breast ultrasonography (US), rather than mammography and breast mag­netic resonance imaging (MRI). Ultrasonography is a very valuable modality in IGM in the posttreatment follow-up phase, as well as its contribution to determining the diagnosis. While the sensitivity of US in detecting lesions is high, its specicity is low in the differential diagnosis of the lesions.
In addition to the algorithm for identied ndings, the radiologist’s comments and recommendations should also be recorded in the breast imaging report. Therefore, the use of the Breast Imaging Reporting and Data System (BI-RADS) classication has been created and, thus, has enabled such interpretations to be noted in standardized form [8]. The score of BI-RADS US includes the denition of the lesion seen, the degree of suspicion, which lesions should be biopsied, and rec­ommendations to the clinician. BI-RADS 2 refers to benign lesions with no risk of malignancy.
In a previous study, 90% and 10% of IGM patients were reported to be dened as BI-RADS 3 and BI-RADS 4 categories sonographically, respectively [3]. IGM often mimics breast cancer clinically and radiologically, and the cases are com­monly diagnosed as breast cancer initially [9]. Since the risk of breast cancer does not increase because of IGM diagnosis throughout the lifetime, the correct diagno­sis is important to avoid unnecessary mastectomy. Therefore, US investigation is greatly benecial in the differential diagnosis.
50
N. Sekmenli
The most common sonographic nding in IGM is usually in the form of inter­connected hypoechoic masses with irregular, ill-dened, and angled contours, including sinus tracts extending into the neighboring parenchyma in heterogeneous echoes in the peripheral sections of the breast (Figs.8 and 9) [2, 5]. The lesions are almost always seen as parallel-orientated in the parenchyma.
Other common sonographic ndings include features such as thickening of the breast skin (Fig.10), enlargement of the ductal structures (Fig.11), mass-like paren- chymal distortion (Fig.12), uniform or heterogeneous masses with regular contours (Fig.13), global edema in the breast tissue (Fig. 14), parenchymal heterogeneity (Fig.15), accumulated dense abscess-like contents (Fig.16), tract formations open­ing to the skin or extending to the subcutaneous parenchyma (Fig. 15), and hypoechogenic areas casting a focal acoustic shadow (Fig.17). Irregular contours, microlobulated angulations, and heterogeneous parenchymal areas often raise the suspicion of malignancy (Fig.18).
Fig. 8 Idiopathic granulomatous mastitis: a 30-year-old woman. Tubular connection (arrows up) extending between the breast lobules and subcutaneous tissue. Subcutaneous collection is seen (arrow to right)
Fig. 9 A 36-year-old woman with IGM.Hypoechoic nodular structures (stars) and tubular connection (arrows)
Imaging Studies inIdiopathic Granulomatous Mastitis
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Fig. 10 A 36-year-old woman with IGM.Multiple irregular hypoechoic masses and collections with tubular connection with ngerlike aspects and thickening of the skin (arrows)
Fig. 11 A 32-year-old woman with IGM.Hypoechoic nodular structure (star) with ductal ectasia (arrows)
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Fig. 12 Idiopathic granulomatous mastitis: a 30-year-old woman. Ill-dened hypoechoic concentrated collection (arrows) is connected with nodular hypoechoic structure (star)
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